Subacromial Pain Syndrome (SAPS)

What is subacromial pain syndrome (SAPS)?

umbrella term for pain in deltoid region and is the most common MSK shoulder disorder in primary care setting

Why are we using SAPS instead of impingement?

clinical diagnosis NOT structural

pt perceives structural issue as not being able to be fixed

cause of SAPS

compromise of subacromial space --> irritation of one or more structures within that space

tendon overload and degeneration

what makes the coracoacromial arch?

coracoacromial ligament + acromion + coracoid process

functions of coracoacromial arch

rigid, non-expandable roof over the humeral head

boundaries of subacromial space

superior - acromion, coracoacromial ligament, AC joint

inferior - humeral head, rotator cuff

contents of subacromial space

supraspinatus tendon

subacromial bursa

LHB tendon

types of SAPS: primary (outlet) impingement

related to structural deficits --> narrowing of subacromial space

types of SAPS: secondary (non-outlet) impingement

movement related

no evidence of narrowing

types of SAPS: posterior (internal) impingement

occurs during max abd + ER of shoulder

intra-articular

what causes primary impingement?

repetitive mechanical compression against a fixed anatomical obstruction

structural narrowing of space

what are potential causes of narrowing subacromial space?

hooked acromion

osteophytes

thickened coracoacromial ligament

what structures are compressed with primary impingement?

supraspinatus

LHBT

subacromial bursa

who has primary impingement?

middle-aged or older adults (>40)

onset of primary impingement

insidious, chronic onset

moi of primary impingement

repetitive overhead trauma - think occupational (painters) and recreational (swimmers)

primary impingement can progress along shoulder continuum. what is the shoulder continuum?

bursitis --> tendinopathy --> partial thickness RC tear --> full thickness RC tear

clinical presentation of primary impingement

lateral/anterior shoulder pain, vaguely over deltoid

painful arc (60-120) - decreased pain above and below

variable ROM deficits

aggravating factors for primary impingement

overhead reaching

lifting arm above shoulder height

activities that require sustained or repeated elevation

laying on affected side

force couples

review these :)

secondary impingement is due to

functional narrowing of an anatomically normal subacromial space

what is secondary impingement a result of?

abnormal kinematics - posterior RC tightness or capsule tightness, decreased neuromuscular control and weakness, GH instability/capsular laxity, posture dysfunction

what structures are compressed with secondary impingement?

consistent across primary and secondary

supraspinatus, subacromial bursa, LHB tendon

who gets secondary impingement?

younger, active/overhead populations

<40

repetitive activites

onset of secondary impingement

insidious with onset of sx gradually building over time

clinical presentation of secondary impingement

anterior/lateral shoulder pain

variable ROM limitations

painfularc

aggravating factors for secondary impingement

reaching OH, difficulty sleeping, reaching across body

can secondary impingement progress along continuum?

yes

what causes posterior (internal) impingement?

intra-articular pinching of posterosuperior cuff and labrum during ABER postion

what is the ABER position?

abd + max ER (late cocking phase of throwing)

what occurs in posterior impingement?

rep throwing stretches anterior capsule

posterior capsule tightens (GIRD develops) shifting humeral head postsup during ABER

combination increases contact pressure b/w greater tub and postsup glenoid rim causing pinching of the INF/SS and postsup labrum

scap dysfunction/dyskinesis compounds this by failing to reposition glenoid

who gets posterior impingement?

OH throwing athletes

rep OH ABER position

clinical presentation of posterior impingement

diffuse shoulder pain with onset at posterior shoulder during late cocking phase of throwing

decreased throwing velocity

dead arm

complaints of instability

Michener SAPS Test Cluster

painful arc

Hawkin's-Kennedy Test

Neer Sign

Resisted Infraspinatus (ER) Test)

Empty Can (Jobe's) Test

positive Michener test cluster

3/5 positive tests

Park SAPS test cluster

+ painful arc

+ Hawkin's-Kennedy test

+ resisted infraspinatus (ER) test or ERLS

positive Parks cluster

3/3 positive tests

special tests for long head of the biceps

yergason test

speeds test

special tests for the scapula

scapular assistace test

can a single test diagnose SAPS?

nah

Hawkins Kennedy Test Procedure

Patient position: seated

Examiner places patient's arm in 90° of shoulder flexion and 90° of elbow flexion

Examiner stabilizes scapula with one hand and with other hand on patient's elbow adds passive IR of the GH joint

Hawkins Kennedy Test Positive Test

Reproduction of patient's familiar shoulder pain during IR

Neer's Sign Test Procedure

Patient position: seated or standing

Examiner position: behind or beside patient

Examiner stabilizes the scapula with one hand

With other hand passively flex the patient's arm (in maximum IR) forward to maximal flexion

Positive Neer's Sign

Reproduction of patient's familiar shoulder pain

Resisted Infraspinatus (ER) Test Procedure

Patient position: seated or standing

Examiner position: standing in front of patient

Patient's arms at side, both elbows are flexed to 90°

Examiner places palms on dorsum of the patient's hand

Patient is instructed to externally rotate both shoulders against the examiner's resistance

Positive Resisted Infraspinatus (ER) Test

Weakness in external rotation

External Rotation Lag Sign (ERLS) at 20 degrees (infraspinatus) test procedure

Patient position: seated with arm abducted to 20° in the scapular plane

Examiner position: beside patient

Examiner passively externally rotates the humerus to near-maximal range (end range minus 5°)

Examiner continues to support arm at elbow and instructs patient to actively hold the position, examiner then releases wrist

Observe for lag

positive external rotation lag sign (ERLS) at 20 degrees test

Any one of the following:

Patient is unable to hold the position and the arm springs back anteriorly (internally rotates) - lag sign

Inability to hold the test position

If you observe lag sign on 1st attempt; reiterate the instructions, emphasizing that they "hold" the test position and repeat the test

ERLS at 90 degrees (Teres Minor) Test Procedure

Patient position: seated with arm abducted to 90° in the scapular plane

Examiner position: beside patient

Examiner passively externally rotates the humerus to near-maximal range (end range minus 5°)

Examiner continues to support arm at the elbow and instructs patient to actively hold the position, examiner then releases wrist

Observe for lag

Positive ERLS at 90 degrees

(any one of the following)

Patient is unable to hold the position and the arm springs back anteriorly (internally rotates) - lag sign

Inability to hold the test position

If you observe lag sign on 1st attempt; reiterate the instructions, emphasizing that they "hold" the test position and repeat the test

Empty Can Test Procedure

Patient position: seated or standing

Examiner position: standing in front of patient

Patient elevates arms to 90 degrees in scapular plane

Arms are internally rotated so the thumbs are pointing downwards

Examiner applies downward resistance at mid forearm while patient attempts to maintain position

positive empty can test

Pain, weakness, or both compared to unaffected side

speeds test procedure

Patient position: seated or standing

Patient shoulder is flexed to 90° with elbow fully extended and the forearm fully supinated

Examiner applies a downward force at the patient's forearm/wrist

positive speeds test

Reproduction of familiar pain in the bicipital groove/anterior shoulder

yergason test procedure

Patient position: seated or standing (standing is

preferred)

Patient's elbow is flexed to 90°

Examiner stabilizes the patient's elbow with one hand while the other holds the wrist (or can be in "handshake" position)

Patient is asked to supinate the forearm and externally rotate the shoulder at the same time while examiner resists both motions

positive yergason test

Reproduction of familiar pain in the proximal shoulder, specifically the bicipital groove

scapular assistance test procedure

Patient position: standing

Instruct patient to actively elevate arms (scapular plane) overhead - Note where pain/limitations occur

Patient will lower arm and examiner will place one hand over the scapula/acromion

As patient elevates arm, examiner gives light assistive force that facilitates upward rotation of the scapula while other hand supports the inferior angle or medial border to assist posterior tilting

positive scapular assistance test

Reduction of pain in the "painful arc" and improved ROM

key positive findings to RULE IN SAPS

positive impingement signs (Neer, Hawkins, Jobe)

painful arc

pain with isometric resistance

weakness

atrophy (tear)

key negative findings to RULE OUT SAPS

significant loss of motion

instability signs

SAPS key differentials to rule in/out

Rotator Cuff Tear

GH Arthritis

Adhesive Capsulitis

Labral Tears

Instability

Cervical Radiculopathy C5-C6 - Neurogenic weakness mimicking cuff deficit

Red Flags

Referred Pain Sources

• Cervical Spine

• Cardiac Pathology - Left Shoulder

• Gallbladder - Right shoulder

SAPS imaging main takeaway

Imaging findings are common in asymptomatic shoulders, imaging supports but does not replace clinical diagnosis for SAPS

what is the first-line intervention for SAPS

exercise

is surgery recommended for SAPS?

Subacromial decompression and acromioplasty is not recommended for this patient population

is there significant PROM loss with SAPS?

nah

what plane is the painful arc test performed in?

scapular plane (30 degrees anterior to frontal plane)